12.4.2 Acute Complications Of Diabetes Mellitus

Question 1

DKA
Define

Answer 1

• Acute, major life-threatening complication of DM
  Diabetic 13.9mmol/I
  Keto: ketones produced
  Acidosis
• Medical emergency
• Mostly type 1 diabetes

Question 2

Spectrum of DKA and hyperosmolar coma

Answer 2

Pure DKA Ketoacidosis
- Rapid onset
- Marked insulin lack
↕️
Ketaacidosis-Hyperosmolar coma
- Intermediate
↕️
Pure HHS Hyperosmolar coma
- Slow onset
- Mild insulin lack
- Sugar goes very high

Question 3

DKA
Symptoms

Answer 3

• Insidious increased thirst (ie, polydipsia) & urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA).
• Malaise, generalised weakness, and fatigability also can be present
• Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia.
• history of rapid weight loss.
• Altered consciousness in the form of mild disorientation or confusion
• Acute chest pain or palpitations may occur in association with myocardial infarction.
• NB! Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients ECG NB!

Question 4

DKA
Precipitating factors

Answer 4

• Inadequate insulin administration
• Infections (pneumonia, UTI, gastroenteritis, sepsis)
• Infarction (cerebral, myocardial, coronary, mesenteric, etc.)
• Pregnancy
• Use of medications: steroids (glucocorticoids), thiazide diuretics, calcium-channel blockers, propranolol, cocaine, amphetamine

Question 5

DKA
Pathophysiology

Answer 5

Page 47+49
- Lack of inulin -> ⬆️ glucagon -> pro-inflam cytokines-> sugar gets worse -> dehydration (urinate alot)
- Inflammation
- Dehydration (⬆️ hyperglycemia)
- Loss of potassium in urine
- Acidosis (⬆️ Ketone bodies)

Question 6

DKA
Symptoms
Signs

Answer 6

Symptoms
- Nausea and vomiting
- Polyuria / + Thirst
- Abdominal pain
- Shortness of breath (low CO2)

Signs
- Dehydration
➡️Mild: Dry mouth
➡️Severe: Tachycardia, Low BP (d/t ⬇️ circulatory volume)
- Abdominal tenderness (may resemble acute pancreatitis / acute appendicitis)
- Tachypnoea, Kussmaul’s respiration, “Fruity” smell of breath, respiratory distress
- Lethargy, cerebral edema and coma

Question 7

DKA prevention

Answer 7

Educate pt about:
- symptoms of DKA
- precipitating factors
- management of diabetes
- Seek medical attention if persistent vomiting, uncontrolled hyperglycaemia and dehydration

Question 8

Hyperosmolar hyperglycemic syndrome (HHS)

Answer 8

• Hyperosmolar hyperglycemic non-ketotic coma (HONK)
• Mainly seen in elder individuals with type 2 DM
• Characterised by profound hyperglycaemia and dehydration
• Mortality - Variable 10-50%; Most often due to the precipitating illness
• Absence/ Mild ketosis

Question 9

Hypoglycaemia
Classification

Answer 9

Glucose alert value (Level 1)
- Less than 3.9 mmol/L
- Sufficiently low for treatment with fast-acting carbohydrate and dose adjustment of glucose-lowering therapy

Clinically significant hypoglycaemia (Level 2)
- Less than 3.0 mmol/L
- Sufficiently low to indicate serious, clinically important hypoglycaemia

Severe hypoglycaemia (Level 3)
- No specific glucose threshold
- Hypoglycaemia associated with altered physical or mental state requiring external assistance for recovery

Question 10

Hypoglycaemia
Risk Factors

Answer 10

• Insulin/ sulfonylurea treatment
• Polypharmacy
• Previous hypoglycaemia
• Renal impairment
• Cognitive impairment
• Lower level of education
• Irregular meals/ malnutrition
• Depression
• Frailty

Question 11

Hypoglycaemia
Prevention
Symptoms & Signs

Answer 11

HYPOGLYCAEMIA TO BE PREVENTED AT ALL COSTS
- life-threatening complication: blood glucose, 4mmol/I

SYMPTOMS AND SIGNS
- pallor
- sweating
- apprehension
- trembling
- tachycardia
- hunger
- drowsiness
- mental confusion
- seizures
- coma